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The Spine
Composed of 33
vertebrae
7 cervical
12 thoracic
5 lumbar
5 sacral + 4
coccyx (fused)
Act to support the trunk
and transfer muscular
load
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The Spine
Typical Vertebrae
Cervical
Body
Small, wide side to side
Spinous process
Short, bifid, projects posteriorly
Vertebral foramina
Triangular
Transverse processes
Contain foramina
Superior & inferior articulating
processes
Superior facets directed
superoposteriorly
Inferior facets directed inferoanteriorly
Movement allowed
Flexion, extension, lateral flexion,
rotation
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Thoracic
Body
Larger than cervical,heart shaped,bears
two costal demifacets
Spinous process
Long, sharp, projects inferiorly
Vertebral foramen
Circular
Transverse processes
Bear facets for ribs (Except T11&T12)
Superior & inferior articulating
processes
Superior facets directed posteriorly
Inferior facets directed anteriorly
Movement allowed
Rotation, lateral flexion possible but limited
by ribs, flexion & extension prevented
Lumbar
Body
Massive, kidney shaped
Spinous process
Short, blunt, projects posteriorly
Vertebral foramen
Triangular
Transverse processes
Thin & tapered
Superior & inferior articulating
processes
Superior facets directed posteromedially
(or medially)
Inferior facets directed anterolaterally (or
laterally)
Movement allowed
Flexion & extension ; some lateral flexion,
rotation prevented
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Sacrum
Coccyx
Formed by four
rudimentary vertebrae
Remnant of the sceleton
of the tail
Pelvic surface is concave
& smooth
Dorsal surface is convex
& rough
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Atlanto-occipital joints
Atlantoaxial joints
Costovertebral joints
Joints of the vertebral bodies
(intervertebral [IV] discs)
Joints of the vertebral arches
(zygapophysial joints/facet joints)
Sacroiliac joints
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Intervertebral Disc
Notochord & mesenchym derivates
Intervertebral disc - comprised of three parts :
nucleus pulposus
annulus fibrosus
hyaline cartilage end plates
( Williams,1989 ; White III & Pamjabi, 1990 ; Holm,1990 ; Willis & Burton,1992)
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Intervertebral Discs
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Annulus Fibrosus
Annulus Fibrosus
The collagen fibres of the inner two-thirds of the AF sweep around into the
vertebral endplate, forming its cartilagineous component.
The peripheral fibres of the anulus are anchored into the bone of ring apophysis
The arrangement of AF allowing movement between adjacent vertebrae and provides
a strong bond between them
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Annulus Fibrosus
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Annulus Fibrosus
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Annulus Fibrosus
Collagen : 50 70 %
Proteoglycan : 10 20 % H2O <<
Outer side : Collagen type I >>
Tension
Force
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Nucleus Pulposus
Nucleus Pulposus
Collagen : 15%-25% (Collagen type 2 >>)
Proteoglycan : 50% H2O (90%)
Compression
Force
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Disc Problems
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Disc Problems
Disc degeneration
Disc herniation
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Disc Degeneration
Initial degeneration in the human spinal column
occurs in the NP
Characterized by a gradual loss of chondroitin
sulfate and water content loss of turgor and
resilience
With increasing age AF gradually loses some of its
elasticity, particularly posteriorly where it is
relatively thin more easilly separated or even
torn NP protude or herniate - site of weakness in
the AF
Second site of weakness is the thin cartilage
end plate through which nuclear material may
protrude into the underlying cancellous bone of the
vertebral body and thereby form a Schmorls node
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balance
EXTERNAL LOAD
.
Type of work
. Weight of load
. Duration of load
INTERNAL STRENGTH
.
Mechanical insult
.
Mechanical injuries
. Nutritional disturbance
(Pope et al., 1991)
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Degenerative Process
Circumferential tear of A.F./Disc Degeneration
mechanical insult
mechanical injuries
nutrition
natural aging
anatomical variation
( genetic )
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( RADIAL TEAR )
( CIRCUMFERENTIAL TEAR)
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(COMBINED)
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Disc Herniation
Herniation of the NP and parts of disc into or through the AF is well recognized cause of low back pain
(LBP)
95% of lumbar disc herniation (LDH) occur at the L4/5 or L5/S1 levels
As people get older, their NP lose their turgor and become thinner because of dehydration and degeneration.
Flexion of the spine produces compression anteriorly and streching or tension posteriorly toward the thinnest
part or the AF.
If the degeneration of the posterior longitudinal ligament (PLL) and wearing of the AF has occurred, the NP may
herniate into the vertebral canal and compress the spinal cord or the nerve roots of the cauda equina.
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Disc Herniation
Usually occur posterolaterally, where the AF is relatively
thin and poorly suported by either the PLL.
Posterolateral disc herniation more likely to be symptomatic
because of the proximity of the spinal nerve roots.
Localized back pain of disc herniation disc results from
pressure on the PLL and periphery of the AF and from local
inflamation resulting from chemical iritation by substances
from the ruptured NP
Chronic pain resulting from the spinal nerves being
compressed by the herniated disc is reffered to the area
(dermatome) supplied by that nerve
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Disc Herniation
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Disc Herniation
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Disc Herniation
Protrusion I
Protrusion II
Protrusion III
Subligament
Transligament
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Disk Degeneration
Grade 0
: no change
Grade 1
: Local disruption
Grade 2
Grade 3
: Total disruption
( < 10 % )
( > 50 % )
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Disc Herniation
Lumbago
An acute mid and low back pain radiating down
Sciatica
Sciatic Nerves
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Dermatomes
Diagram beside
demonstrated the
dermatomal distribution in
different individuals
(percentage values are for
those in whom at least
exhibit the particular
pattern)
Black area
: 75 %
Shaded area : 50 %
Stippled area : 25 %
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Disc Injury
Occurs most in cervical and lower lumbar spine
Disc compresses nerve roots or duramater (surrounding
spinal cord)
May be due to a combination of excessive loading and
preliminary disc degeneration
AF fibres rupture and fail through fissuring
With age, NP degrades and no longer transfers pressure
across the nucleus
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Middle component
Posterior complex
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DENIS CLASSIFICATION
. System was developed by Denis based on analysis of both plain radiographs
and CT, & has achieved wide acceptance. This notion was developed after
analyzing his own trauma practice.
( Spine, 1983; Clin Orthop, 1984 )
. Three columns paradigm has been Biomechanically tested & found to be Valid
( Panjabi et al., Spine, 1995 )
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DENIS CLASSIFICATION
Combination of four basic mechanism of injury :
. Compression
. Distraction
. Rotation
. Shear
DENIS CLASSIFICATION
Type of
Fracture
Column involvement
_______________________________________________________________
Anterior
Middle
Posterior
_________________________________________________________________________________
Compression
Compression
None
None or distraction
( in severe fractures )
Burst
Compression
Compression
None or distraction
Seat Belt
(Flexion-distraction)
None or Compression
Distraction
Distraction
Fracture-dislocation
Compression and / or
rotation, shear
Distraction and / or
rotation, shear
Distraction and / or
rotation, shear
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The loss of the ability of the spine under physiologic loads to maintain
relationships between vertebrae in such a way that there is neither
damage nor subsequent irritation to the spinal cord or its nerve roots,
and in addition there is no development of incapacitating deformity
or pain
( White & Panjabi, 1990 )
Mechanical Instability :
Facet Joints
Facet Joints
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Sacroiliac Joint
Connects the sacrum to
the ilium
The stability depends on :
Joint configuration - L
shaped
Extensive ligamentous
support
* Sacroiliac ligaments
* Accessory sacroiliac
ligaments
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Spine Musculature
Muscle of the spine are part of
the trunk musculature
Three groups of muscles in
the back : superficial,
intermediate, and deep
group
Deep / intrinsic back muscles
are grouped according to their
relationship to the surface :
superficial, intermediate,
and deep layer
Muscle injury generally occurs
during forcible lengthening
while the muscle is activated
(contracting)
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Proprioceptive Fibers
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Neural Injuries
Spinal injuries damage the cord or the
nerve roots or both
Partial or complete
3 varieties :
1. Neuropraxia
2. Cord Transection
3. Root transection
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Anatomical Levels
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Anatomical Levels
N. C1 Occiput & C1
N. C2 C1 & C2
N. C5 C4 & C5
N. C8 C7 & T1
N. T1 T1 & T2
N. L4 L4 & L5
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Anatomical Levels
Cervical Spine
Level of cord level of bony damage
Level C5 vert. isolates lower cervical
cord, thoracic cord, lumbar & sacral cord
Below C5 vert. partial sparing of the
upper limb
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Anatomical Levels
Between T1 & T10 Vertebrae
1st Lumbar cord seg. ~ T10 Vert.
Transection at T10 Vert. Spares the
thoracic cord, isolates the entire lumbar &
sacral cord
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Anatomical Levels
Below T10 Vertebra
The cord bulge at the T10 & L1 Vert tapers to
an end at the interspace between the L1 & L2
vert.
L2 S4 nerve roots arise from the conus
medullaris cauda equina
Spinal injuries above the T10 vert. cord
transection
Spinal injuries between the T10 & L1 vert.
cord & nerve root lesions
Spinal injuries below the L1 vert. nerve root
lesions
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Injury side :
Contra-lateral side :
power normal
pinprick & temp. sens. absent
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A MIXED SYNDROME
Unclassifiable combination of several syndromes
Small precentage of incomplete SCI do not fit one
of the previous syndromes
SYNDROME CONUS MEDULLARIS
Injury of Sacral cord (conus) & lumbar nerve roots
areflexed bladder, bowel, and lower extremities,
flaccid paralysis in perineum & loss of all bladder
and perianal muscle control
Irreversible : bulbocavernosus r. & perianal wink (-)
CAUDA EQUINA SYNDROME
THANK YOU
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